Basic Information
| Provider Information | |||||||||
| NPI: | 1043340102 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYEGLASS WORLD, LLC 68 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3801 S CONGRESS AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334614140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619659110 | ||||||||
| FaxNumber: | 5616424063 | ||||||||
| Practice Location | |||||||||
| Address1: | 44 E GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606113533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3125279477 | ||||||||
| FaxNumber: | 3122229558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | BEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5619659110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.